Compelling commentary on children's health

Over the past few weeks I’ve had several questions from
parents on a problem referred to as sleep feeding.What is it? Why do babies do it?What can I do about it?And (perhaps the most interesting
issue) where did this problem come from?Here’s my take.And I’ll
modify this over time as I learn more.

What is sleep
feeding?

Quite simply, sleep
feeding is a popular term used to describe babies who feed nearly exclusively
when asleep.Better put, these are
babies who have such a difficult time feeding when awake that their sleep state
appears to relax them to the point that they are more organized and able to
feed. Parents are consequently forced to put their baby to sleep in order to
help them maintain their intake.Mention of the problem in our current body of medical literature is
scarce, if not absent.

But while
the popular discussion of sleep feeding is new, the problem is not.I describe the phenomenon of sleep
feeding in my 2007 book, Colic Solved –
The Essential Guide to Infant Reflux and the Care of Your Crying,
Difficult-to-Soothe Baby (see page 46).And over the past 10 years I’ve evaluated and treated many
babies with sleep feeding.

Most babies I have seen with sleep feeding represent
variants where some feeding can be completed while awake but only with a great
deal of effort.

What causes sleep
feeding?

As someone who has
made a living evaluating feeding and digestive disorders in babies, I have
found that the vast majority of infants with sleep feeding in my practice
suffer with symptoms of acid reflux.Here’s what happens:

2.Painful esophageal inflammation leads to painful
feeding marked by frequent pulling from the bottle or nipple.

3.If not treated, babies continue to struggle to feed and
potentially develop an aversion to feeding.

4.Parents discover that feeding goes better when sleeping
and the pattern is facilitated in order to maintain appropriate milk intake.

Another problem that can predispose to a pattern of sleep
feeding in babies is milk protein allergy.Allergy can create inflammation just like that seen with
acid reflux.And while we always
have to consider anatomic problems in any baby with feeding issues, those with
anatomic issues in the throat or swallowing tube are unlikely to feed any
better when asleep.In other
words, the plumbing won’t change with state of arousal.

It’s important to look beyond the pattern of feeding while
asleep in order to identify what’s behind an infant’s feeding issue.In other words, the nature and pattern
of feeding while awake often offers clues to the presence of reflux esophagitis
in a baby.And the same is true
for allergic inflammation in the gut.Other signs and symptoms as detailed in my book will help identify the
baby with subtle signs of reflux or painful feeding.

In theory, any condition that interferes with smooth,
comfortable feeding could lead a parent to help a baby develop sleep
feeding.Consequently acid reflux
should not be assumed to be the primary problem.It needs to be diagnosed based on clinical criteria.

What can parents do
with a sleep feeding baby?

It’s important for parents to understand that sleep feeding appears to
be a reactive phenomenon rather than a primary problem or condition.In other words, feeding during sleep is
a pattern that develops out of necessity in a child with an issue that prevents
effective feeding while awake. What’s the primary issue?Consequently our attention needs to be
on identifying what’s going on to create such problematic feeding.This is not an issue that you can
resolve on the Internet or through the advice of others in a chat room.While support is critical, a hands-on
assessment by a trained expert is critical.

Here are a few things to keep in mind when getting help for
your baby:

·Look and
treat.Look for and treat
conditions that predispose to painful or difficult feeding.Acid reflux and allergy need to be
firmly excluded.

·Enlist an
expert.If acid reflux has
been firmly excluded, consider an assessment by a pediatric speech pathologist
or occupational therapist experienced in infant feeding.Two things are critical here:pediatric specialization and infant
feeding experience.You want to
find a therapist who spends all of their time with children and has extensive
clinical experience in infant feeding disorders.If you live in a small community, seeking the input of a
speech pathologist or OT who dabbles in children may be a waste of time.Beat a path to the nearest city with
pediatric services.If your
pediatrician isn’t immediately comfortable assessing your baby look for consultation
with a pediatric gastroenterologist.

·Simple
feeding difficulty or long standing aversion?Recognize that when a baby’s primary feeding problem is
identified and treated early, normal patterns of eating while awake can often
be resumed.The baby older than
5-6 months of age, however, may potentially have aversive behaviors that persist
long after the primary problem has been addressed.This mandates therapy by a professional experienced in
infant feeding therapy.

·Never
force feed.While tempting,
force feeding a baby with an underlying feeding issue is likely to compound the
stress, fear and anxiety already associated with the bottle or breast.

Why are parents
talking about sleep feeding?

This
is possibly the most interesting question surrounding the sleep feeding
phenomenon.Why wasn’t anyone
talking about this last year, for example.Is this some sort of new issue?A modern epidemic perhaps?Hardly.As I
mentioned, sleep feeding has been around as long as reflux has plagued
babies.The current discussion is
just one step in the sequence of recognizing the problem of reflux in babies.

It’s interesting to note that “sleep feeding” or “dream
feeding” as a concept has become popularized recently due to social networking
– Chat rooms and other forms of social media are allowing mothers with sleep
feeding babies to share their experiences and recognize that their baby’s
unusual behavior may not be that unusual.This is a clear example of how e-patients empower themselves and
actually get answers.

Should your pediatrician know about sleep feeding?

I
would have to say that as someone who takes referrals from 200-300 well-trained
pediatricians, knowledge about sleep feeding and its relationship to acid
reflux disease is not standard.Remember that acid reflux disease in infancy and childhood is still a
relatively new concept.And considering
that this phenomenon hasn’t been reported in the medical literature I wouldn’t
expect it to be in the minds of primary care physicians.Keep in mind, however, that there
remain physicians in practice who don’t believe that acid reflux disease is
much of a concern in children.This is one more reason to be informed.

Most babies suffering with sleep feeding will typically
demonstrate other signs of reflux or allergy.But bringing these issues to the forefront during a doctor’s
visit is more likely to result in intervention and appropriate treatment.

Help me to help you

If your baby is a sleep feeder I would
love to hear from you.While I
can’t offer medical advice, our discussion will help me learn about the
patterns of sleep feeding encountered by parents.Email colic1 at mac dot com.

As if The Great Wall of Bottles at Babies R Us wasn't long enough, late 2007 brought us yet another bottle system: The Adiri Natural Nurser. This beautifully bulbous, BPA-free back loading baby feeder resembles something from Woody Allen’s 1973 classic, Sleeper. Compelling really.

So is this medical innovation or marketing marvel? Is exquisite form met with exquisite function? It’s unclear.

Once beyond the wow factor, parents have to make the decision about whether this bottle will actually make a difference in what’s important: air swallowing. Remember that one of the most important factors in choosing a bottle is a baby’s capacity to sustain a comfortable, air-tight latch. In many cases this can only come through trial and error since an infant’s palate and latch will vary from child to child. What works for one baby won't work for the next.

While parents can feel empowered that they have yet one more option to consider when playing bottle roulette, only time, research and maternal testimony will tell us whether Adiri’s function exceeds what’s currently available on the market. For parents, change to meet what your baby needs and remember that in many cases, chaotic feeding is a consequence of acid reflux and other treatable conditions.

For Adiri, here’s what I would do:Get research. The bottle’s website has a conspicuous absence of any peer-reviewed literature suggesting that this bottle performs differently than other bottles. A new study from Boston Children’s Hospital published last year suggests that the liner systems such as that found in the Playtex Drop-in System beautifully replicate the swallowing and breathing pattern seen in breast-fed babies.Take a better position. It’s unclear how this bottle is different. Why as a pediatrician should I recommend this bottle to my patients? My grandmother used to tell me that looks are only skin deep. I need more.Dump colic. Finally, I might suggest avoiding the term ‘colic’ in marketing materials. Nothing is as unmistakably 20th century as indiscriminate use of the c-word. If you're confused, pick up a copy of Colic Solved.Give your publicist a raise. They’re doing a remarkable job. This thing’s had more press than Britney Spears and Barack Obama combined.

Hiding vegetables has become all the rage. The Sneaky Chef by Missy Chase Chapine and Deceptively Delicious by Jessica Seinfeld have hit the charts telling parents how to covertly deliver ‘healthy food’ to kids. Last week’s lawsuit involving the two sneaky chefs has me wondering if we should be fooling our kids at all when it comes to feeding.

Masquerading food is about us and our insecurities. It has little to do with what children actually need. Children have a remarkable capacity to take what they need when they need it. Our obsession with micromanaging vitamins, nutrients, colors and bites contributes to a stressful feeding encounter. I would go so far as to suggest that the food fight mindset supports an ideology of nutritionism which has been popularized by Michael Pollan in his fascinating new book, In Defense of Food. It’s worth a read if you’re concerned about the way we eat … or feed.

The interference that we create between a child and her food will do little to improve their long-term health or relationship with real food. Parents would do well to remember Ellyn Satter’s Division of Responsibility. And when we realize that parents make miserable dieticians, things can only improve.

You could say that I’m the kind of pediatrician who believes that a bottle is a bottle. Technology may be changing that.

A study out of Boston Children’s Hospital published late last year in the journal Pediatric Research compared the way babies fed from hard-walled bottles (Avent) and with that of soft-walled bottles (Playtex DROP-INS system). Using sophisticated instruments the researchers were able to simultaneously measure breathing, sucking, swallowing and blood oxygen in babies when feeding from each type of bottle system. They were able to identify differences in the way babies feed and breath with each bottle system and compared that with breastfed babies.

Some of the findings were very interesting:

Breastfeeding. Breast fed babies are able to separate swallowing from breathing.Soft-walled bottle. Babies fed with the soft-walled bottles, like breast fed babies, coordinate their swallowing and breathing. They swallow less frequently and are less likely to swallow while breathing.Hard-walled bottle. Babies fed with hard-walled bottles swallowed randomly and tended to swallow more frequently. Levels of blood oxygen in these babies was lower when compared with those babies who were breast fed or fed with soft-walled systems.

So despite popular trends towards certain bottles, it would appear that the Playtex DROP-INS system does a better job of helping a baby coordinate their sucking and breathing. And as the authors describe, this coordination is likely to lead to less air swallowing. As I discuss at length in my book, Colic Solved, air swallowing is the root of all gas in babies and anything we can to minimize it’s access can only help a baby’s cause.

As technology advances, our ability to identify subtle differences in the way babies feed with different bottles will change the way we look at feeding. Once a market driven process, our decisions regarding feeding systems will ultimately be defined by physiologically identifiable differences such as those seen in the Goldfield study.

As always, the breast is best. For those who can’t, the future looks bright.

What is it about a baby’s birthday that marks the transition from formula to cow’s milk? The question of when and why we stop using formulas relates to when babies become dependent upon solids. Both breast milk and formula bring babies to the point of weaning where they are able to support themselves on a variety of age-appropriate foods. This may happen late during a baby’s first year or early into the second year of life.

During the first year we pay close attention to the mineral and protein concentration in a baby’s diet. This is why we mandate that babies be fed only breast milk or formula. The first birthday marks the point where a baby’s body is able to handle many of the foods that adults eat. The additional protein, potassium and sodium found in cow’s milk, for example, is handled by a baby’s kidneys and intestinal tract without a problem. Another reason cow's milk is inappropriate under a year is its lack of appropriate levels of iron, linoleic acid, vitamin E.

But a baby could conceivably lag into her second year feeding Enfamil, Similac or Good Start without any repercussions. It is assumed, however, that toddlers at this point are receiving protein and vitamins from solid food sources. Infant formulas alone are unlikely to provide everything that a toddler needs for growth and development.

For many toddlers, milk may be considered a supplement, a nearly irrelevant source of bonus calories. For those who struggle with solids, however, milk is a key supplement. But as pediatricians we assume that for most kids the buffer offered by milk is a good thing. In fact, whole milk is recommended over lower fat milks to cover for the calories that some picky toddlers lack.

So while the 12-month point for eliminating formula may seem fairly arbitrary, it’s safe to say that it arises from the timing of what babies do on their own (wean) as well as the development of their bodies to take things beyond breast milk or formula. But like so many other things in parenting and pediatrics, we’ve got more wiggle room than you know.

Daily occurrence in my clinic: A toddler is brought in for evaluation. During the course of our visit any type whining, fussing, or protest triggers the appearance of the grazing canister from mom’s bag. Grazing canisters are those small, colorful plastic snack containers that are suited for the fast, easy delivery of refined carbohydrates anytime, anywhere. And then, hand-to-mouth, the fish-shaped crackers or bear-shaped graham crackers disappear as fast as they appeared.

This mindless move to preoccupy our children with food is perceived by most of us as innocent. Peace at any cost. And what harm does it do really? Perhaps more than we think.

It rewards marginal behavior.
It reinforces that we deal with boredom and other emotions with food.
Unless it is a designated snack time, it isn’t consistent with good feeding structure.

I don’t say this to pass judgment but find it to be a common practice with subtle consequences that few parents think about. It appears that our relationship with food begins a lot earlier than we think.